Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 15, Number 10, October 2024, pages 261-266

Combination Therapy With Asciminib and Ponatinib as a Bridge to Brexucabtagene Autoleucel and Maintenance in a Patient With Relapsed Refractory Philadelphia Positive B-Cell Acute Lymphoblastic Leukemia

Figures

Figure 1.
Figure 1. Right cheek involvement with Ph+ B-cell ALL. Arrow indicates 11 mm right cheek skin involvement with Ph+ B-cell ALL, showing hypermetabolic activity on PET scan (SUV 5.9). ALL: acute lymphoblastic leukemia; PET: positron emission tomography; SUV: standard uptake value.
Figure 2.
Figure 2. Extramedullary disease involving T9 vertebral body (a) and T10 vertebral body (b). Arrows indicate hyperintense enhancing lesions on MRI, involving T9 (right) and T10 (left) vertebral body with Ph+ B-cell ALL. ALL: acute lymphoblastic leukemia; MRI: magnetic resonance imaging.

Table

Table 1. Timeline of Treatment and Response Assessment
 
SNTimelineTreatmentExtramedullary disease at the time of treatmentResponse by MRD flow cytometry (%)Response by BCR-ABL1 PCR (%)*
*Includes peripheral blood and bone marrow samples at different time points. MRD: minimal residual disease; PCR: polymerase chain reaction; MTX: methotrexate; IT: intrathecal; IV: intravenous; CNS: central nervous system; PET: positron emission tomography; NA: not available.
1October 8, 2020LALA-94 protocol + imatinib 400 mg daily (performed at outside hospital)None0.14%NA
2December 9, 2020Chemo + dasatinib 140 mg dailyNone19.4%5.3121%
3January 19, 2021Blinatumomab (clinical trial), January 11, 2021NoneNANegative, 0.001, 0.0008
4September 22, 2021Blinatumomab + nilotinibNoneNegative0.012
5October 27, 2021Dose reduced - hyperCVAD-part B + nilotinib
D1: MTX 100 mg/m2 (2 h), 400 mg/m2 over 22 h; D2-3 cytarabine 1 g/m2 q 12 h		Right cheek mass
Abdominal nodal mass		NegativeNegative
6February 8, 2022Ponatinib single agentNoneNANegative
7March 8, 2022Ponatinib 15 mg daily, vincristine 1 mg IV and prednisone 60 mg day 1 - 5 Q 4 weeksNoneNANegative, 4.2%
8December 16, 2022Repeat reduced dose hyper-CVD-part B
Methotrexate 100 mg/m2 for 2 h then 400 mg/m2 for 22 h
Cytarabine 500 mg/m2 q12 h for 2 days
IT chemotherapy 70 mg cytarabine day 2 and 12 mg methotrexate on day 8
Started ponatinib 15 mg daily from day 5
Increased dose to 30 mg daily from day 10		PET scan showed extramedullary disease- involving T9 vertebral body, fourth rib and pelvic lymphadenopathy
CNS disease detected		0.0470.395 (ABL kinase mutation negative)
9January 25, 2023Ponatinib 30 mg daily with asciminib 40 mg twice a day (maintenance prior to brexu-cel)Vertebral bone diseaseNA0.0071
10March 20, 2023Brexucabtagene-autoleucelBone lesions involving thoracic and vertebra, resolution of pelvic lymphadenopathyNegativeNegative on day 60 bone marrow biopsy/PET scan negative at day 100.
11April 6, 2023Resumed ponatinib 15 mg daily with asciminib 40 mg twice a day (maintenance post brexu-cel)None9.312.96 (ABL1 kinase mutation negative)
12February 22, 2024Repeat course of blinatumomab (later nilotinib 200 mg twice a day was added)NoneNegative (May 14, 2024)Negative (July 17, 2024)